Quality Improvement Priorities Research Articles

Measuring the Quality of Personal Care in Patients Undergoing Radiotherapy for Prostate Cancer

AimsTo describe the quality of the non-technical component of the care (personal care) of patients receiving radical radiotherapy for prostate cancer and to identify elements of personal care that should be priorities for quality improvement. Materials and methodsOne hundred and eight patients undergoing radiotherapy for localised prostate cancer completed a self-administered questionnaire that asked them to rate the importance of 143 non-technical elements of care and to rate the quality of their own care with respect to each element. The elements that a patient rated as both ‘very important’ and less than ‘very good’ were deemed to be his priorities for improvement. The priorities of the population were established by ranking the elements based on the percentage of patients who identified them as a priority (importance/quality analysis). ResultsThe response rate was 65%. The percentage of elements rated ‘very good’ varied from patient to patient: median 79% (interquartile range 69–92%). The percentage of elements rated either ‘very good’ or ‘good’ was higher: median 96% (interquartile range 86–98%). Nonetheless, almost every patient rated at least some elements of his care as less than optimal, regardless of the cut-off point used to define optimal quality. Patients assigned their lowest quality ratings to elements relating to the quality of the treatment environment and comprehensiveness of additional services available to them. However, patients rated most of these elements as relatively unimportant, and importance/quality analysis identified elements of care relating to communication of information about the disease and its treatment as the highest priorities for quality improvement. ConclusionsMost patients rated most elements of their personal care as very good, but almost all were able to identify some elements that were less than optimal. When ratings of quality were integrated with ratings of importance, elements relating to communication emerged as the patients' highest priorities for quality improvement.

Identifying priorities for quality improvement at an emergency Department in Ghana

BackgroundHealthcare quality improvement (QI) is a global priority, and understanding the perspectives of frontline healthcare workers can help guide sustainable and meaningful change. We report a qualitative investigation of emergency department (ED) staff priorities for QI at a tertiary care hospital in Ghana. The aims of the study were to educate staff about the World Health Organization’s (WHO) definition of quality in healthcare, and to identify an initial focus for building a departmental QI program.MethodsSemi-structured interviews were conducted with ED staff using open-ended questions to probe their understanding and valuation of the six dimensions of quality defined by the WHO. Participants were then asked to rank the dimensions in order of importance for QI. Qualitative responses were thematically analyzed, and ordinal rank-order was determined for quantitative data regarding QI priorities.ResultsTwenty (20) members of staff of different cadres participated, including ED physicians, nurses, orderlies, a security officer, and an accountant. A majority of participants (61%) ranked access to emergency healthcare as high priority for QI. Two recurrent themes - financial accessibility and hospital bed availability - accounted for the majority of discussions, each linked to all the dimensions of healthcare quality.ConclusionsED staff related all of the WHO quality dimensions to their work, and prioritized access to emergency care as the most important area for improvement. Participants expressed a high degree of motivation to improve healthcare quality, and the study helped with the development of a departmental QI program focused on the broad topic of access to ED services.

Chemical and Light Extinction Characteristics of Atmospheric Aerosols in Suburban Nanjing, China

This work reports the chemical and light extinction characteristics of the atmospheric particles collected from January to November 2014 in suburban Nanjing. Size-segregated measurement results showed that more than 80% of the major aerosol components were concentrated in PM2.5. The concentration of PM2.5 was highest in winter and lowest in autumn. Specifically, K+ concentration peaked in late spring indicating heavy influences from straw burning, while sulfate concentration was highest in summer and its daytime concentration was also higher than its nighttime concentration, both reflecting a significant role of photochemical production. Nevertheless, except for sulfate, all other components had higher concentrations during nighttime, signifying the role of unfavorable meteorological conditions in exacerbating the air pollution. The IMPROVE formula was employed, which can reconstruct the PM2.5 mass and light extinction well. The light extinction was mainly contributed by (NH4)2SO4 and NH4NO3 (together 58.3%). Mass concentrations of all PM2.5 components increased significantly with the increase of pollution levels, but nitrate increased most rapidly; correspondingly, the contribution of nitrate to light extinction also increased quickly when pollution became heavy. Such results were different from those observed in Beijing-Tianjin-Hebei where sulfate increased most quickly. Our results thus highlight that reduction of vehicular NO2 is likely a priority for air quality improvement in Nanjing. Back trajectory analysis showed the dominance of the local air mass and the one from Huanghai, yet the air mass originated from Bohai, and passed though Shandong and north of Jiangsu province could deliver highly-polluted air to Nanjing, as well.

Diagnostic Assessments of Service Quality in a Continuing Care Retirement Community (CCRC): an Exploratory Study

ABSTRACTThis study assesses service quality and suggests customized strategies for improvement of the service quality in a continuing care retirement community (CCRC). Questionnaires based on the SERVQUAL framework and adapted for CCRCs were distributed to 293 CCRC residents first to measure their perceived importance and subsequently asses the performance of the CCRC on 25 service quality attributes. Descriptive analysis, confirmatory factor analysis, paired-samples t-test, and regression were used to analyze the data from 118 respondents who participated in both surveys. The results indicated that four service-quality attributes (one item in the reliability dimension and three items in the responsiveness dimension) were the priorities for service quality improvement. Theoretical and practical implications are discussed and recommendations are made for future research in the CCRC context.

Setting Quality Improvement Priorities for Women Receiving Systemic Therapy for Early-Stage Breast Cancer by Using Population-Level Administrative Data.

Purpose Routine evaluation of quality measures (QMs) can drive improvement in cancer systems by highlighting gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact at the population level. We developed an approach that uses both variation in performance and number of patients affected by the QM to set priorities for improving the quality of systemic therapy for women with early-stage breast cancer (EBC). Patients and Methods Patients with EBC diagnosed from 2006 to 2010 in Ontario, Canada, were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. Individual QMs within a panel of 15 QMs previously developed to assess the quality of systemic therapy across four domains (access, treatment delivery, toxicity, and safety) were ranked on interinstitutional variation in performance (using interquartile range) and the number of patients who were affected; then the two rankings were averaged for a summative priority ranking. Results We identified 28,427 patients with EBC who were treated at 84 institutions. The use of computerized physician electronic order entry for chemotherapy, emergency room visits or hospitalizations during chemotherapy, and timely receipt of chemotherapy were identified as the QMs that had the largest potential to improve quality of care at a system level within this cohort. Conclusion A simple ranking system based on interinstitutional variation in performance and patient volume can be used to identify high-priority areas for quality improvement from a population perspective. This approach is generalizable to other health care systems that use QMs to drive improvement.

Reconciling patient and provider priorities for improving the care of critically ill patients: A consensus method and qualitative analysis of decision making.

BackgroundProviders have traditionally established priorities for quality improvement; however, patients and their family members have recently become involved in priority setting. Little is known about how to reconcile priorities of different stakeholder groups into a single prioritized list that is actionable for organizations.ObjectiveTo describe the decision‐making process for establishing consensus used by a diverse panel of stakeholders to reconcile two sets of quality improvement priorities (provider/decision maker priorities n=9; patient/family priorities n=19) into a single prioritized list.DesignWe employed a modified Delphi process with a diverse group of panellists to reconcile priorities for improving care of critically ill patients in the intensive care unit (ICU). Proceedings were audio‐recorded, transcribed and analysed using qualitative content analysis to explore the decision‐making process for establishing consensus.Setting and participantsNine panellists including three providers, three decision makers and three family members of previously critically ill patients.ResultsPanellists rated and revised 28 priorities over three rounds of review and reached consensus on the “Top 5” priorities for quality improvement: transition of patient care from ICU to hospital ward; family presence and effective communication; delirium screening and management; early mobilization; and transition of patient care between ICU providers. Four themes were identified as important for establishing consensus: storytelling (sharing personal experiences), amalgamating priorities (negotiating priority scope), considering evaluation criteria and having a priority champion.ConclusionsOur study demonstrates the feasibility of incorporating families of patients into a multistakeholder prioritization exercise. The approach described can be used to guide consensus building and reconcile priorities of diverse stakeholder groups.

Engaging Learners in Health System Quality Improvement Efforts.

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

A Study on Quality Dimension and Improvement Priority for Enhancing University Educational Service Satisfaction

Purpose This study is on the priority for improving students satisfaction in university educational service. It explores the dimension of service quality and analyzes the relationship among quality elements, service satisfaction, and loyalty. Methods This paper performs empirical studies by questionnaire survey. The Timko model is used for finding the degree of possible improvement of quality elements, and structural equation and regression models are used to analyze the effect of them on service satisfaction and loyalty. Also, explanatory factor analysis is used to investigate the quality determinants. Results The quality dimension is composed of curriculum, employment support, interaction with outsiders, start-up support, learning support, counselling, and administration service. Curriculum, learning support, and administration service are positively correlated with service satisfaction, and service satisfaction has a positive effect on loyalty. Counselling service is an attractive element, and curriculum, start-up support, and learning support are indifferent elements. Conclusion Comprehensive analysis shows that curriculum, academic advisor, and administration service have high priorities for improving educational service satisfaction. Key words: University Education, Educational Service Quality, Educational Service Satisfaction, Improvement Priority

Driving quality improvements of radiation treatment services through a centralized performance management approach.

188 Background: Radiation treatment services are delivered in 16 facilities spread across the province of Ontario, centralized through Cancer Care Ontario’s oversight of quality of care, equipment, hospital funding, clinical and technical guidelines. Methods: In order to ensure high quality care, Cancer Care Ontario employs a systematic approach performance management, whereby facilities are held accountable to achieving provincial quality targets. For radiation treatment, the quality improvement priorities that have leveraged this approach over the last 10 years have included: reduction of wait times to consultation; reduction of wait times to start of treatment; adoption of Intensity Modulated Radiation Therapy (IMRT) where appropriate; and implementation of peer review for treatment plans. In each case, key performance indicators were developed for use in provincial scorecards designed to focus the attention of local clinical and administrative leadership. Regular performance discussions with senior leaders took place throughout implementation, and targeted intervention occurred with facilities that were lagging behind their peers. Results: See table. Conclusions: The ability to centrally monitor the implementation of quality improvement initiatives across a large jurisdiction, and to hold the leadership of each facility accountable to provincial targets through regular feedback and escalation, has been a key component of highly successful change management initiatives in radiation treatment in Ontario. [Table: see text]

Examining measurement properties of the consumer-based cancer care value index (CCCVI) survey: A measure to identify quality improvement priorities in cancer care.

222 Background: Current approaches to measuring the quality of cancer care may not produce sufficient information to enable providers to structure care that aligns closely with their patients’ preferences. To close this gap, we developed the Consumer-based Cancer Care Value Index (CCCVI) survey, which assesses the aspects of cancer care that patients value the most and how their values align with their experience in receiving cancer care. Methods: The CCCVI field test included 721 adults who received cancer care in the last 12 months from 4 geographically diverse cancer care centers, including patients with varying stages of cancer, types of cancer, types of treatment (e.g., surgery, radiation, medical oncology), and demographic characteristics. The survey included items that asked patients to directly rate the “importance” of 24 aspects of cancer care, along with 24 corresponding items that measured the “frequency” with which they received each aspect of care. We evaluated the reliability and validity of the survey items, and developed “value grids” plots which visually depicted the “importance” scores against the “frequency” scores. We conducted subgroup analysis to examine income and racial/ethnic disparities in the extent of misalignment between patients’ values and experiences. Results: The survey demonstrated good internal consistency reliability (Cronbach’s alpha = 0.91) and acceptable-to-good construct and criterion validity. Value grids identified potential areas of improvement in the areas of how doctors communicate and how quickly patients get care. The subgroup analysis showed the most misalignments between patients’ values and experiences in the aspects of doctor communication for lower-income patients and in the aspects of getting care quickly for patients from racial/ethnic minority groups. Conclusions: The CCCVI survey is a reliable and valid tool for cancer care providers to identify top priority areas (i.e., high-importance but low-frequency areas) to facilitate their quality improvement efforts. It also recognizes subgroup variations in the misalignment between patients’ values and care experiences.

Nationwide disparities in testicular cancer care delivery: Racial, ethnic, and economic markers of patient vulnerability.

421 Background: Testis cancer is often curable, yet early presentation is a key determinant of survival and treatment morbidity. Testis cancer affects the young, who have less consistent primary care access. This may impede timely mobilization of complex healthcare resources needed for cancer care. We analyze the National Cancer Database (NCDB) for disparity in disease-specific outcomes. Methods: The NCDB identified adult males with testicular tumors (2004-2013). Four outcomes were selected as markers of care delays: higher stage presentation (defined as stage III+), large primary lesion at diagnosis, time to orchiectomy and overall mortality. Key exposures included race/ethnicity, socioeconomic factors and insurance status. Outcomes were assessed with multivariable hazards regression (survival) or logistic regression (others). Results: 31,964 men were eligible. Seventeen percent had higher stage presentation, 29% had a large primary, and 9.9% had delayed orchiectomy and 4.8% died during follow up. All outcomes were associated with multiple markers of patient vulnerability at the p < 0.001 level. The most consistent and greatest magnitude association was insurance status (e.g. for mortality Medicaid HR 1.9, 95% CI 1.6-2.3, uninsured HR 1.7, 95% CI 1.5-2.1, for large primary Medicaid OR 1.8, 95% CI 1.7-2.0, uninsured OR 2.1, 95% CI 2.0-2.3 [referent private payer]). In addition to markers of vulnerability, center case volume and travel burden were also associated with poor outcomes (p < 0.001). Conclusions: We find association between severity of disease and markers of patient vulnerability. Insurance had the greatest magnitude and most consistent association with poor outcomes and is therefore a priority for quality improvement. As access to primary care is expanded for the testis cancer population with the Affordable Care Act, it will be important to assess whether gains in coverage translate to improvements in cancer outcomes.

Using Experience-based Co-design with older patients, their families and staff to improve palliative care experiences in the Emergency Department: A reflective critique on the process and outcomes

BackgroundIncreasing use of emergency departments among older patients with palliative needs has led to the development of several service-level interventions intended to improve care quality. There is little evidence of patient and family involvement in developmental processes, and little is known about the experiences of − and preferences for – palliative care delivery in this setting. Participatory action research seeking to enable collaborative working between patients and staff should enhance the impact of local quality improvement work but has not been widely implemented in such a complex setting. ObjectivesTo critique the feasibility of this methodology as a quality improvement intervention in complex healthcare settings, laying a foundation for future work. Settingan Emergency Department in a large teaching hospital in the United Kingdom. MethodsExperience-based Co-design incorporating: 150h of nonparticipant observation; semi-structured interviews with 15 staff members about their experiences of palliative care delivery; 5 focus groups with 64 staff members to explore challenges in delivering palliative care; 10 filmed semi-structured interviews with palliative care patients or their family members; a co-design event involving staff, patients and family members. Findingsthe study successfully identified quality improvement priorities leading to changes in Emergency Department-palliative care processes. Further outputs were the creation of a patient-family-staff experience training DVD to encourage reflective discussion and the identification and application of generic design principles for improving palliative care in the Emergency Department. There were benefits and challenges associated with using Experience-based Co-design in this setting. Benefits included the flexibility of the approach, the high levels of engagement and responsiveness of patients, families and staff, and the impact of using filmed narrative interviews to enhance the ‘voice’ of seldom heard patients and families. Challenges included high levels of staff turnover during the 19 month project, significant time constraints in the Emergency Department and the ability of older patients and their families to fully participate in the co-design process. ConclusionExperience-based Co-design is a useful approach for encouraging collaborative working between vulnerable patients, family and staff in complex healthcare environments. The flexibility of the approach allows the specific needs of participants to be accounted for, enabling fuller engagement with those who typically may not be invited to contribute to quality improvement work. Recommendations for future studies in this and similar settings include testing the ‘accelerated' form of the approach and experimenting with alternative ways of increasing involvement of patients/families in the co-design phase.

Leveraging lean principles in creating a comprehensive quality program: The UCLA health readmission reduction initiative

IntroductionUCLA Health embarked to transform care by integrating lean methodology in a key clinical project, Readmission Reduction Initiative (RRI). MethodsThe first step focused on assembling a leadership team to articulate system-wide priorities for quality improvement. The lean principle of creating a culture of change and accountability was established by: 1) engaging stakeholders, 2) managing the process with performance accountability, and, 3) delivering patient-centered care. The RRI utilized three major lean principles: 1) A3, 2) root cause analyses, 3) value stream mapping. ResultsBaseline readmission rate at UCLA from 9/2010–12/2011 illustrated a mean of 12.1%. After the start of the RRI program, for the period of 1/2012–6/2013, the readmission rate decreased to 11.3% (p<0.05). ConclusionTo impact readmissions, solutions must evolve from smaller service- and location-based interventions into strategies with broader approach. As elucidated, a systematic clinical approach grounded in lean methodologies is a viable solution to this complex problem.

Identifying priorities for data quality improvement within Haiti׳s iSanté EMR system: Comparing two methods

ObjectivesThe aim of this case study was to compare two alternative strategies for prioritizing data elements for data quality assessment (DQA) in a routine health management information system. The study used data from iSanté, a multi-site electronic medical record implemented by the Haitian Ministry of Health. We described and compared two prioritization strategies: (1) a Delphi process drawing iterative feedback from clinicians and stakeholders responsible for monitoring and evaluation (M&E) of health programs to identify consensus priorities for data on HIV patients; and (2) a process using burden of disease estimates from Haiti to establish priorities for data on primary care patients. MethodsThe Delphi process included 26 individuals across 6 institutions, including clinicians and M&E specialists. Through three rounds of questionnaires, the stakeholders provided input for prioritization of 13 indicators for completeness, accuracy and timeliness of HIV data. The burden of disease prioritization process revealed that cardiovascular disease contributed to the greatest number of disability-adjusted life-years (DALYs). This resulted in the selection of 16 data quality indicators for primary care data. ResultsBoth methods informed the definition of a set of automated data quality queries to assess internal validity, completeness, and timeliness using logic and clinical plausibility. The Delphi process benefited from stakeholder input, but was lengthy in process. The burden of disease prioritization process was objective and easier to implement, but lacked stakeholder buy-in. ConclusionsA hybrid approach guided by both disease burden and stakeholder input may be most beneficial for prioritizing data elements for DQA.

Improving childhood nutrition and wellness in South Africa: involving mothers/caregivers of malnourished or HIV positive children and health care workers as co-designers to enhance a local quality improvement intervention

BackgroundA significant proportion of children admitted to a hospital in a South African sub-district in 2010 were severely malnourished and - when concurrently HIV positive - were not correctly initiated on antiretroviral therapy. Audit data over a subsequent four year period revealed that 60 % of malnourished children admitted to the hospital were HIV positive. To supplement an ongoing local quality improvement (QI) intervention addressing poor nutritional outcomes in children in this setting, Experience-based Co-design (EBCD) was used to enhance previously low levels of mother, carer and staff engagement.MethodsEBCD was implemented over an 8 month period. Non-participant observation was conducted comprising a total of 10 h in 5 different clinical locations. Semi-structured interviews were undertaken with 14 purposively selected staff members as well as 10 mothers/caregivers. The staff interviews were audio-taped whilst the mothers/caregiver interviews were filmed; both sets of experiences were analysed for key ‘touchpoints’. Mothers/caregivers and staff participated in separate feedback events and then came together to identify their shared priorities for improving the service. Participants worked together in 3 smaller co-design teams to implement improvements.ResultsThere was overlap in staff and mother/carer views as to their priorities for QI. However, whilst staff typically highlighted pragmatic issues, mothers/caregivers were more likely to identify experiential and relational issues. A total of 38 QI interventions were proposed after the priorities had been discussed and delegated to the 3 co-design teams; 25 of these changes had been implemented or were being planned for by the end of the study period. Examples included: a point of care blood machine being bought to shorten the time in the emergency department whilst waiting for laboratory results; a play area being organised for children attending the HIV clinic; the development of three standard operating procedures to improve clinical handover and waiting times; and privacy screens installed to improve privacy in reception.ConclusionsThe impact of EBCD was noted both in practical improvements focused on a better experience for mothers/caregivers and children within the system and in reflections from stakeholders as to the value added to the ongoing QI intervention by the co-design process.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1574-4) contains supplementary material, which is available to authorized users.

Identifying Continuous Quality Improvement Priorities in Maternal, Infant, and Early Childhood Home Visiting.

The purpose of this article was to describe a methodology to identify continuous quality improvement (CQI) priorities for one state's Maternal, Infant, and Early Childhood Home Visiting program from among the 40 required constructs associated with 6 program benchmarks. The authors discuss how the methodology provided consensus on system CQI quality measure priorities and describe variation among the 3 service delivery models used within the state. Q-sort methodology was used by home visiting (HV) service delivery providers (home visitors) to prioritize HV quality measures for the overall state HV system as well as their service delivery model. There was general consensus overall and among the service delivery models on CQI quality measure priorities, although some variation was observed. Measures associated with Maternal, Infant, and Early Childhood Home Visiting benchmark 1, Improved Maternal and Newborn Health, and benchmark 3, Improvement in School Readiness and Achievement, were the highest ranked. The Q-sort exercise allowed home visitors an opportunity to examine priorities within their service delivery model as well as for the overall First Teacher HV system. Participants engaged in meaningful discussions regarding how and why they selected specific quality measures and developed a greater awareness and understanding of a systems approach to HV within the state. The Q-sort methodology presented in this article can easily be replicated by other states to identify CQI priorities at the local and state levels and can be used effectively in states that use a single HV service delivery model or those that implement multiple evidence-based models for HV service delivery.

Setting quality improvement priorities for women receiving systemic therapy (ST) for early stage breast cancer (EBC) using population level administrative data.

299 Background: Routine evaluation of evidence informed quality measures (QM) can drive improvement in cancer systems by highlighting potential gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact on quality at a population level. We aimed to use variation in performance to set priorities for improving the quality of ST for women with EBC. Methods: EBC cases diagnosed 2006 – 2010 in Ontario, Canada were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. A panel of QMs, previously developed to be operationalized for administrative data, was applied to reflect the quality of ST. Each QM was evaluated in all patients who met the inclusion criteria for the individual measure. QMs were ranked based on institutional variation in performance using the mean absolute difference (MAD). Results: We identified 28,303 patients, treated at 84 institutions. The performance of each QM is listed in Table 1. Timely receipt of ST, febrile neutropenia (FN) secondary prophylaxis, emergency room visits or hospitalizations, receipt of hormonal therapy (HT) and the use of surveillance imaging represented the 5 QM that demonstrated the greatest variation. Conclusions: Considerable institutional-level variation highlights potentially actionable areas of improvement [Table: see text]

Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study

To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care.

Consumer Quality Index Chronic Skin Disease (CQI-CSD): a new instrument to measure quality of care from the patient's perspective

Assessing quality of care from the patient's perspective is considered to be highly relevant. As a standardized instrument in dermatology was lacking, we developed a patient experience questionnaire regarding chronic skin disease care: the Consumer Quality Index Chronic Skin Disease (CQI-CSD). (i) To evaluate the dimensional structure of the CQI-CSD, (ii) to assess its ability to distinguish between hospitals according to patients' experiences with quality of care, (iii) to explore patients' experiences with dermatological care and priorities for quality improvement according to the patients, and (iv) to optimize the questionnaire based on psychometric results and stakeholders' input. In a cross-sectional study 5647 adult patients who received dermatological care in the past 12months in 20 hospitals were randomly selected and invited to fill out the questionnaire. Overall 1160 of 3989 eligible respondents (29% response rate, 30-87 per hospital) were included for analysis. The CQI-CSD comprised seven scales with high internal consistency (Cronbach's α=0·74-0·92). The instrument's discriminative power was limited. Patients were positive about the care provided by nurses and doctors, but the provision of information by healthcare providers, accessibility of care and patient involvement could be improved. We optimized the CQI-CSD, resulting in a revised questionnaire containing 65 items. In conclusion, the CQI-CSD is a useful instrument to measure patient experiences with dermatological care.

Surgical Site Infections in Pediatric Plastic Surgery

INTRODUCTION: Surgical site infections (SSIs) are responsible for significant morbidity and healthcare costs. The US Department of Health and Human Services has identified the reduction of SSIs as a national priority for patient safety and quality improvement. Preventing SSIs is dependent on a clear understanding of modifiable risk factors for targeted intervention. In Pediatric Plastic Surgery, our understanding of risk factors for SSIs has been limited by small sample size, nonstandard definitions, and single-center retrospective data. The objective of this study is to use a large prospective national database to analyze clinical risk factors for SSI in children undergoing plastic surgery operations. METHODS & MATERIALS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Peds) is a quality improvement database that prospectively collects demographic data, perioperative risk factors, and 30-day postoperative morbidity outcomes across 56 participating pediatric institutions. Data for patients less than 18 years old undergoing plastic surgery operations were extracted from the NSQIP-Peds 2012 and 2013 databases using CPT codes. Risk factors for SSI were determined with univariate analyses and multivariate logistic regression. RESULTS: Among 11,656 patients, there were 5520 (47%) craniofacial, 4431 (38%) skin/soft tissue, 747 (6.4%) extremity, 728 (6.2%) transcranial, 211 (1.8%) breast/chest wall, and 19 (0.2%) gastrointestinal/genitourinary operations. Mean age at surgery was 5.5 (± 3.8) years and 52% were male. The overall rate of SSI was 0.7%. There were 57 (0.5%) superficial SSIs, 11 (0.1%) deep SSIs, and 10 (0.1%) organ space SSIs. On univariate analysis, inpatient status (p<0.05), increased total operative time (p<0.01), increased length of hospital stay (p<0.01), and younger age at time of surgery (p<0.05) were risk factors for SSI. Following multivariate logistic regression analyses, increased total operative time (p<0.01) was an independent predictor of SSI. Children undergoing extremity or transcranial operations had a higher proportion of SSI than children undergoing skin/soft tissue, craniofacial, breast/chest wall, and/or gastrointestinal/genitourinary operations (p<0.05). Wound classification and ASA classification were not predictive of SSI. CONCLUSIONS: The overall rate of SSI in children undergoing plastic surgery operations is low. This analysis of a large prospective multicenter database provides a high level of evidence regarding risk factors for SSI in the pediatric plastic surgery population and has implications for quality improvement by identifying modifiable factors for targeted intervention.